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Community Associated Resistant Bacteria:What Bugs and What Drugs Work Against Them?. Lilly Immergluck, MD Associate Professor of Pediatrics Divisions of General Pediatrics and Pediatric Infectious Diseases Morehouse School of Medicine March 1, 2006. Background Information.

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community associated resistant bacteria what bugs and what drugs work against them

Community Associated Resistant Bacteria:What Bugs and What Drugs Work Against Them?

Lilly Immergluck, MD

Associate Professor of Pediatrics

Divisions of General Pediatrics and Pediatric Infectious Diseases

Morehouse School of Medicine

March 1, 2006

emergence of antimicrobial resistance

Resistant Bacteria

Mutations

XX

Resistance Gene Transfer

New Resistant Bacteria

Campaign to Prevent Antimicrobial Resistance in Healthcare Settings

Emergence of Antimicrobial Resistance

Susceptible Bacteria

selection for antimicrobial resistant strains

Campaign to Prevent Antimicrobial Resistance in Healthcare Settings

Resistant StrainsRare

Antimicrobial

Exposure

Resistant Strains

Dominant

x

x

x

x

x

x

x

x

x

x

x

x

Selection for antimicrobial-resistant Strains
what bugs are we talking about in pediatrics
What “Bugs” are we talking about…in Pediatrics?
  • Community-associated Methicillin Resistant Staphylococcus aureus
  • Drug Resistant Streptococcus pneumoniae
types of mrsa
Types of MRSA
  • BRSA- Borderline MRSA
  • MRSA- related to mecA gene=ORSA
  • Hospital associated MRSA
  • Community associated MRSA
mechanism of resistance for mrsa
Mechanism of Resistance for MRSA

Mec A gene

Staph

Staph

antibiotic

staphylococcal chromosomal cassette mec iv type 4 scc mec type iv
Staphylococcal chromosomal cassette mec IV, type 4(SCC mec type IV)

Derensinski S. Clin Infect Dis 2005:562-73

emergence of usa 300 clone
Emergence of USA 300 clone
  • Result of insertion of SCCmecA type IV
  • Donor staph isolate is MSSA
  • Differences from HA-MRSA:
    • Gene cassette coding for methicillin resistance
    • Carriage of plasmids encoding resistance to antibiotics of other classes
    • Associated virulence factor
scc mec types i v
SCCmec types I-V

Derensinski S. Clin Infect Dis 2005:562-73

staphylococcus sp
Staphylococcus sp.
  • “Isolates of staphylococci that are shown to carry the mecA gene, or that produce PBP2a, the gene product, should be reported as oxacillin resistant”
epidemiology of mrsa
Epidemiology of MRSA
  • First described in 1961
  • Approximately 50% of Staphylococcus aureus infections in ICU in US due to MRSA
risk factors for hospital acquired mrsa in adults
Risk Factors for Hospital acquired MRSA in Adults
  • Prolonged/recurrent antibiotic exposure
  • Prolonged hospitalization or ICU
  • Chronically ill
  • Nursing home residence
  • Dialysis or Malignancy
ha mrsa prevalence
HA-MRSA Prevalence

Lowy, Frank,Staphylococcus Infections. NEJM. August, 1998

definition of community associated mrsa
Definition of Community-associated MRSA

Salgado, Farr, Calfee Clin Infect Dis, 2003

epidemiology of community acquired mrsa
Epidemiology of Community acquired MRSA
  • Case Report in Chicago
  • Outbreak among high school wrestling team in Vermont
  • Reports have occurred in Chicago, Minnesota, North Dakota, Dallas, Winnipeg, Toronta, and in Australia
headlines to catch our attention
Headlines to catch our attention…
  • Methicillin-Resistant Staphylococcus aureus Infections Among Competitive Sports Participants --- Colorado, Indiana, Pennsylvania, and Los Angeles County, 2000—2003
  • Four Pediatric Deaths from Community-Acquired Methicillin-Resistant Staphylococcus aureus -- Minnesota and North Dakota, 1997-1999
slide20
“Study Finds Spread of Resistant Staph”

By THE ASSOCIATED PRESS Published: April 7, 2005, NY Times

pro football after medical scare giants center improves
“PRO FOOTBALL; After Medical Scare, Giants' Center Improves”
  • November 4, 2004, Thursday
  • By LYNN ZINSER (NYT); Sports Desk
  • Late Edition - Final, Section D, Page 4,
  • “At first, Giants center Shaun O'Hara said he had no idea why his swollen calf was causing so much alarm among team trainers last week. He knew nothing about the staph infections that had struck seven Miami Dolphins last year, hospitalizing two of them, or of…”
fatal pediatric infections from ca mrsa
Fatal Pediatric Infections from CA-MRSA

Source: Centers for Disease Control and Prevention, Atlanta , October 1999 / HOSPITAL INFECTION CONTROL

minnesota surveillance study 1997
Minnesota Surveillance Study, 1997

Naimi,LeDell et al Clin Infect Dis 2001

maybe as simple as this
Maybe as simple as this…

courses.washington.edu, accessed from web 2/28/06

or more severe as this
Or more severe as this…

www.emedicine.com/ped, accessed Feb 28, 2006

clinical presentation of children with ca mrsa
Clinical Presentation of Children with CA-MRSA

Herold, Immergluck, et al JAMA 1998

summary of risk factors for ca mrsa
Summary of Risk Factors for CA-MRSA

Eady, Cove, Curr Opin Infect Dis, 2003

slide32

“D Test” – positive reaction

Inducible

clindamycin resistance

(erm-mediated)

…another example

15 - 26 mm

Photos courtesy of J. Jorgensen and K. Fiebelkorn.

slide33

“D Test” – negative reaction

NO induction

(msrA-mediated erythromycin resistance)

treatment of ca mrsa
Treatment of CA-MRSA
  • Options are better than hospital acquired-MRSA
  • Almost all are clindamycin susceptible
  • Trimethoprim-sulfamethoxazole
  • Role of quinolones
ha mrsa susceptibility pattern
Profile 1

Clindamcin R

Erythromycin R

Oxacillin R

Penicillin R

Vancomycin S

Profile 2

Cefazolin S

Clindamycin R

Erythromycin R

Oxacillin R

Penicillin R

Vancomycin S

HA-MRSA susceptibility pattern
ca mrsa often susceptible to
Clindamycin

Erythromycin

Fluoroquinolones

Linezolid

Rifampin

Tetracyclines

Trimeth-sulfa

Vancomycin

CA-MRSA often susceptible to:
treatment regimens
Treatment Regimens
  • Severe infections, multi drug resistant infections
    • Vancomycin
    • Daptomycin
    • Linezolid (pneumonia)
    • Quinopristin/dalfopristin
  • Limited infections, less severe
    • TMP-SMZ
    • Linezolid
    • ?No treatment
data in atlanta area
Data in Atlanta Area
  • Adult studies
  • Pediatric studies
risk factors for ca mrsa colonization in adults
Risk Factors for CA-MRSA Colonization in Adults
  • HIV infection
    • Lower risk if HIV infected and receiving antibiotics within 3 months before admission
  • History of skin or soft tissue infection
  • Hospitalization within preceding year
  • Receipt of antibiotics within 3 months before admission

Hidron, AI, Kourbatova, EV, et al, Clin Infect Dis 2005

susceptibility of isolates by pulsed field type
Susceptibility of Isolates, by pulsed-field type

Hidron, AI, Kourbatova, EV, et al, Clin Infect Dis 2005

preliminary data for atlanta children
Preliminary Data for Atlanta Children

3169 Staphylococcus aureus isolates from 1/2002-12/2004

    • 656 (21%) CA-MRSA isolates by phenotype
    • 485 (15%) HA-MRSA isolates by phenotype
  • Based on data collected from Egleston and Scottish Rite Hospitals
incidence of ssti due to s aureus isolates among scottish rite er patients 2002 2004
Incidence of SSTI due to S. aureus isolates among Scottish Rite ER Patients, 2002-2004

Isolates/10,000 ER visits

incident ca mrsa isolates from ssti s at egleston and scottish rite er patients
Incident CA-MRSA Isolates from SSTI’s at Egleston and Scottish Rite ER Patients

Isolates/10,000 ER visits

where do we go from here
Where do we go from here?
  • Surveillance of children who are colonized with CA-MRSA
  • Understand risk factors for colonization and subsequent infections due to CA-MRSA
  • Understand household transmission of CA-MRSA
  • Develop strategies for eradication of colonization